Skip to content
Healthinsurance — Includes — Healthorganizations — Approving — Enzyme — Anthrax — Documentation — Medicare

Medicare's Step Therapy Approach: A Guide

Medicare's approach to treatment referred to as Step Therapy, where prescription drug benefits are provided in a sequential manner that requires patients to try lower-cost or generic drugs before accessing pricier brand-name medications, aiming to reduce overall healthcare costs.

,   and  Administrator
2 min read
Medicare's approach to prescription drug coverage, also known as step therapy, involves requiring...
Medicare's approach to prescription drug coverage, also known as step therapy, involves requiring patients to try less expensive treatments before moving on to more costly ones, if appropriate for their specific condition. This process aims to ensure that patients receive appropriate care while also controlling healthcare costs.

Medicare's Step Therapy Approach: A Guide

Rewritten Article:

Stepping up to higher-cost prescriptions in Medicare Part D isn't a free-for-all. Instead, plans require beneficiaries to take a trip down the medicine cabinet's cheaper options first. This approach, known as step therapy, saves insurers some cash but can leave individuals waiting for effective treatment.

Whether you're tossing pills under Part D, Part B, or even Part C, your plan might ask for a prior authorization before greasing the wheels on prescription drug coverage. When it comes to Part D, this process is known as a coverage determination. And step therapy is a specific type of prior authorization where your plan wants you to try a less costly pill before shelling out for the pricier option.

So, why does Medicare play hard-to-get?

Part D plans have a list of covered drugs, called a formulary. Each drug roughly fits into one of several tiers, with higher-tier drugs costing more bucks. Plans employ step therapy to keep a lid on their drug bills, encouraging folks to start with a lower-tier medication that treats their medical condition just as effectively—and avoids the expense of the costlier drugs if they're satisfactory.

If a cheaper med doesn't cut it, the plan holds back before letting you升华 (or "step up") to the more expensive option. Even some Part C plans, those with prescription drug coverage baked in, might ask for step therapy depending on their specific policies.

Got an example of step therapy in action?

Expect your doctor to set you on a trial run of a generic or biosimilar version of the brand drug, or an entirely different, lower-tier drug that gets the job done. But if you're a good candidate for a step-dance, Medicare will take a peek at factors like your medical history, age, sex, diagnosis, and any current medications before obliging and telling you or your doc about the requirement.

Here's how "step therapy" works in motion:

Let's say a doc prescribes lisinopril (Prinivil and Zestril) for pumping the brakes on high blood pressure.

Step 1: When lisinopril is insufficient alone (or "resistant" to treatment), your doctor rolls out Aliskiren (Tekturna).

Step 2: Medicare Part D requests a detour with losartan (Cozaar) and hydrochlorothiazide.

Step 3: If these meds are ineffective, Part D approves Aliskiren for resistant hypertension.

Feel like you're walking, not running, in your treatment?

If you believe a specific prescription medication is crucial, you can request an exception by submitting a letter to your plan or asking your doctor to do so. This letter should explain why you can't wait to try the cheaper alternative first, citing potential negative health effects if you do.

Claiming an exception is possible for parts B, C, and D, with Part C plans often making a decision within 72 hours.

  1. Health organizations emphasize the importance of following the step therapy process in Medicare Part D, where beneficiaries are required to try cheaper medication options before being approved for more expensive ones.
  2. During the step therapy process, if a generic or biosimilar version of a brand drug, or a lower-tier drug, does not work effectively, health insurance, including Medicare, may consider approving the more expensive option.
  3. The documentation for requesting a potential exception to the step therapy process should include an explanation of why waiting for the cheaper alternative could have negative effects on the individual's health.
  4. In certain cases, health organizations may approve the initial prescription without going through the step therapy process, based on the individual's medical history, age, sex, diagnosis, and current medications.

Read also:

    Latest